l_132_ nd General Assembly Regular Session Sub. H. B. No

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1 132nd General Assembly Regular Session Sub. H. B. No A B I L L To amend sections , , and of the Revised Code regarding the practice of certified registered nurse anesthetists BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: Section 1. That sections , , and of the Revised Code be amended to read as follows: Sec A certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. In this capacity as an advanced practice registered nurse, a certified nurse-midwife is subject to division (A) of this section, a certified registered nurse anesthetist is subject to division (B) of this section, a certified nurse practitioner is subject to division (C) of this section, and a clinical nurse specialist is subject to division (D) of this section. (A) A nurse authorized to practice as a certified nursemidwife, in collaboration with one or more physicians, may Ñd64urgwquueevuy6jezyes-Ó d64urgwquueevuy6jezyes

2 Sub. H. B. No. 191 Page 2 provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse's education and certification, and in accordance with rules adopted by the board of nursing. No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition, except in emergencies. Division (A) of this section does not prohibit a certified nurse-midwife from performing episiotomies or normal vaginal deliveries, or repairing vaginal tears. A certified nurse-midwife may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with section of the Revised Code. (B)(1) A nurse authorized to practice as a certified registered nurse anesthetist, with the supervision and in the immediate presence of a physician, podiatrist, or dentist, may administer anesthesia and perform anesthesia induction, maintenance, and emergence, and may perform with supervision preanesthetic preparation and evaluation, postanesthesia care, and clinical support functions, do all of the following consistent with the nurse's education and certification, and in accordance with rules adopted by the board. The physician, podiatrist, or dentist supervising a certified registered nurse anesthetist must be actively engaged in practice in this state. When a certified registered nurse anesthetist is supervised by a podiatrist, the nurse's scope of practice is limited to the anesthesia procedures that the podiatrist has the authority under section of the Revised Code to perform. A certified registered nurse

3 Sub. H. B. No. 191 Page 3 anesthetist may not administer general anesthesia under the supervision of a podiatrist in a podiatrist's office. When a certified registered nurse anesthetist is supervised by a dentist, the nurse's scope of practice is limited to the anesthesia procedures that the dentist has the authority under Chapter of the Revised Code to perform: (a) Perform and document evaluations and assessments during the perianesthesia period, which may include ordering and evaluating one or more diagnostic tests and consulting with one or more other health professionals; (b) Establish anesthesia care plans; (c) Determine whether planned anesthesia is appropriate; (d) Obtain informed consent for anesthesia care; (e) Select and order anesthesia; (f) In the immediate presence of a physician, podiatrist, or dentist, administer anesthesia and perform anesthesia induction, maintenance, and emergence; (g) Perform clinical functions that are either of the following: (i) Specified in the clinical experience standards established for nurse anesthetist education programs by a national accreditation organization selected by the board of nursing; (ii) Completed pursuant to a physician consultation. (h) When performing clinical functions as provided in this section, order fluids, treatments, drugs, and one or more diagnostic tests and evaluate the results of such tests;

4 Sub. H. B. No. 191 Page 4 (i) As necessary for patient management and care in the perianesthesia period, select, order, and administer fluids, treatments, and drugs for conditions related to administration of anesthesia; (j) Direct registered nurses, licensed practical nurses, and respiratory therapists to do any of the following that they are authorized by law to do for patient management and care in either the perianesthesia period or when the certified registered nurse anesthetist performs clinical functions: (i) Provide supportive care as necessary for patient management and care, including monitoring vital signs, conducting electrocardiograms, and performing intravenous therapy; (ii) Administer fluids, treatments, and drugs to treat conditions related to administration of anesthesia. (k) Perform and document postanesthesia care preparation and evaluation; (l) Perform postanesthesia care assessments, including on admission to or release or discharge from postanesthesia recovery areas; (m) Select, order, and administer pain relief therapies during the perianesthesia period. (2) Division (B)(1) of this section does not authorize a certified registered nurse anesthetist to prescribe a drug for use outside the facility or other setting where the certified registered nurse anesthetist provides care. (3) The physician, podiatrist, or dentist supervising a certified registered nurse anesthetist must be actively engaged

5 Sub. H. B. No. 191 Page 5 in practice in this state. When a certified registered nurse anesthetist is supervised by a podiatrist, the nurse's scope of practice is limited to the anesthesia procedures that the podiatrist has the authority under section of the Revised Code to perform. A certified registered nurse anesthetist may not administer general anesthesia under the supervision of a podiatrist in a podiatrist's office. When a certified registered nurse anesthetist is supervised by a dentist, the nurse's scope of practice is limited to the anesthesia procedures that the dentist has the authority under Chapter of the Revised Code to perform. (C) A nurse authorized to practice as a certified nurse practitioner, in collaboration with one or more physicians or podiatrists, may provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse's nursing specialty, consistent with the nurse's education and certification, and in accordance with rules adopted by the board. A certified nurse practitioner may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices in accordance with section of the Revised Code. When a certified nurse practitioner is collaborating with a podiatrist, the nurse's scope of practice is limited to the procedures that the podiatrist has the authority under section of the Revised Code to perform. (D) A nurse authorized to practice as a clinical nurse specialist, in collaboration with one or more physicians or podiatrists, may provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve, and manage health care within

6 Sub. H. B. No. 191 Page 6 the nurse's nursing specialty, consistent with the nurse's education and in accordance with rules adopted by the board. A clinical nurse specialist may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices in accordance with section of the Revised Code. When a clinical nurse specialist is collaborating with a podiatrist, the nurse's scope of practice is limited to the procedures that the podiatrist has the authority under section of the Revised Code to perform. Sec As used in this chapter: (A) "Pharmacy," except when used in a context that refers to the practice of pharmacy, means any area, room, rooms, place of business, department, or portion of any of the foregoing where the practice of pharmacy is conducted. (B) "Practice of pharmacy" means providing pharmacist care requiring specialized knowledge, judgment, and skill derived from the principles of biological, chemical, behavioral, social, pharmaceutical, and clinical sciences. As used in this division, "pharmacist care" includes the following: (1) Interpreting prescriptions; (2) Dispensing drugs and drug therapy related devices; (3) Compounding drugs; (4) Counseling individuals with regard to their drug therapy, recommending drug therapy related devices, and assisting in the selection of drugs and appliances for treatment of common diseases and injuries and providing instruction in the proper use of the drugs and appliances; (5) Performing drug regimen reviews with individuals by

7 Sub. H. B. No. 191 Page 7 discussing all of the drugs that the individual is taking and explaining the interactions of the drugs; (6) Performing drug utilization reviews with licensed health professionals authorized to prescribe drugs when the pharmacist determines that an individual with a prescription has a drug regimen that warrants additional discussion with the prescriber; (7) Advising an individual and the health care professionals treating an individual with regard to the individual's drug therapy; (8) Acting pursuant to a consult agreement with one or more physicians authorized under Chapter of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery, if an agreement has been established; (9) Engaging in the administration of immunizations to the extent authorized by section of the Revised Code; (10) Engaging in the administration of drugs to the extent authorized by section of the Revised Code. (C) "Compounding" means the preparation, mixing, assembling, packaging, and labeling of one or more drugs in any of the following circumstances: (1) Pursuant to a prescription issued by a licensed health professional authorized to prescribe drugs; (2) Pursuant to the modification of a prescription made in accordance with a consult agreement; (3) As an incident to research, teaching activities, or chemical analysis;

8 Sub. H. B. No. 191 Page 8 (4) In anticipation of orders for drugs pursuant to prescriptions, based on routine, regularly observed dispensing patterns; (5) Pursuant to a request made by a licensed health professional authorized to prescribe drugs for a drug that is to be used by the professional for the purpose of direct administration to patients in the course of the professional's practice, if all of the following apply: (a) At the time the request is made, the drug is not commercially available regardless of the reason that the drug is not available, including the absence of a manufacturer for the drug or the lack of a readily available supply of the drug from a manufacturer. (b) A limited quantity of the drug is compounded and provided to the professional. (c) The drug is compounded and provided to the professional as an occasional exception to the normal practice of dispensing drugs pursuant to patient-specific prescriptions. (D) "Consult agreement" means an agreement that has been entered into under section of the Revised Code. (E) "Drug" means: (1) Any article recognized in the United States pharmacopoeia and national formulary, or any supplement to them, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or animals; (2) Any other article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or animals;

9 Sub. H. B. No. 191 Page 9 (3) Any article, other than food, intended to affect the structure or any function of the body of humans or animals; (4) Any article intended for use as a component of any article specified in division (E)(1), (2), or (3) of this section; but does not include devices or their components, parts, or accessories. (F) "Dangerous drug" means any of the following: (1) Any drug to which either of the following applies: (a) Under the "Federal Food, Drug, and Cosmetic Act," 52 Stat (1938), 21 U.S.C.A. 301, as amended, the drug is required to bear a label containing the legend "Caution: Federal law prohibits dispensing without prescription" or "Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian" or any similar restrictive statement, or the drug may be dispensed only upon a prescription; (b) Under Chapter or of the Revised Code, the drug may be dispensed only upon a prescription. (2) Any drug that contains a schedule V controlled substance and that is exempt from Chapter of the Revised Code or to which that chapter does not apply; (3) Any drug intended for administration by injection into the human body other than through a natural orifice of the human body; (4) Any drug that is a biological product, as defined in section of the Revised Code. (G) "Federal drug abuse control laws" has the same meaning as in section of the Revised Code

10 Sub. H. B. No. 191 Page 10 (H) "Prescription" means all of the following: (1) A written, electronic, or oral order for drugs or combinations or mixtures of drugs to be used by a particular individual or for treating a particular animal, issued by a licensed health professional authorized to prescribe drugs; (2) For purposes of sections , , , , and of the Revised Code, a written, electronic, or oral order for naloxone issued to and in the name of a family member, friend, or other individual in a position to assist an individual who there is reason to believe is at risk of experiencing an opioid-related overdose. (3) For purposes of sections , , , and of the Revised Code, a written, electronic, or oral order for a drug to treat chlamydia, gonorrhea, or trichomoniasis issued to and in the name of a patient who is not the intended user of the drug but is the sexual partner of the intended user; (4) For purposes of sections , , , , , , , , , and of the Revised Code, a written, electronic, or oral order for an epinephrine autoinjector issued to and in the name of a school, school district, or camp; (5) For purposes of Chapter and sections , , , and of the Revised Code, a written, electronic, or oral order for an epinephrine autoinjector issued to and in the name of a qualified entity, as defined in section of the Revised Code. (I) "Licensed health professional authorized to prescribe drugs" or "prescriber" means an individual who is authorized by

11 Sub. H. B. No. 191 Page 11 law to prescribe drugs or dangerous drugs or drug therapy related devices in the course of the individual's professional practice, including only the following: (1) A dentist licensed under Chapter of the Revised Code; (2) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner who holds a current, valid license to practice nursing as an advanced practice registered nurse issued under Chapter of the Revised Code; (3) A certified registered nurse anesthetist who holds a current, valid license to practice nursing as an advanced practice registered nurse, but only to the extent of the nurse's authority under division (B) of section of the Revised Code; (4) An optometrist licensed under Chapter of the Revised Code to practice optometry under a therapeutic pharmaceutical agents certificate; (4) (5) A physician authorized under Chapter of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery; (5) (6) A physician assistant who holds a license to practice as a physician assistant issued under Chapter of the Revised Code, holds a valid prescriber number issued by the state medical board, and has been granted physician-delegated prescriptive authority; (6) (7) A veterinarian licensed under Chapter of the Revised Code. (J) "Sale" or "sell" includes any transaction made by any

12 Sub. H. B. No. 191 Page 12 person, whether as principal proprietor, agent, or employee, to do or offer to do any of the following: deliver, distribute, broker, exchange, gift or otherwise give away, or transfer, whether the transfer is by passage of title, physical movement, or both. (K) "Wholesale sale" and "sale at wholesale" mean any sale in which the purpose of the purchaser is to resell the article purchased or received by the purchaser. (L) "Retail sale" and "sale at retail" mean any sale other than a wholesale sale or sale at wholesale. (M) "Retail seller" means any person that sells any dangerous drug to consumers without assuming control over and responsibility for its administration. Mere advice or instructions regarding administration do not constitute control or establish responsibility. (N) "Price information" means the price charged for a prescription for a particular drug product and, in an easily understandable manner, all of the following: (1) The proprietary name of the drug product; (2) The established (generic) name of the drug product; (3) The strength of the drug product if the product contains a single active ingredient or if the drug product contains more than one active ingredient and a relevant strength can be associated with the product without indicating each active ingredient. The established name and quantity of each active ingredient are required if such a relevant strength cannot be so associated with a drug product containing more than one ingredient

13 Sub. H. B. No. 191 Page 13 (4) The dosage form; (5) The price charged for a specific quantity of the drug product. The stated price shall include all charges to the consumer, including, but not limited to, the cost of the drug product, professional fees, handling fees, if any, and a statement identifying professional services routinely furnished by the pharmacy. Any mailing fees and delivery fees may be stated separately without repetition. The information shall not be false or misleading. (O) "Wholesale distributor of dangerous drugs" or "wholesale distributor" means a person engaged in the sale of dangerous drugs at wholesale and includes any agent or employee of such a person authorized by the person to engage in the sale of dangerous drugs at wholesale. (P) "Manufacturer of dangerous drugs" or "manufacturer" means a person, other than a pharmacist or prescriber, who manufactures dangerous drugs and who is engaged in the sale of those dangerous drugs. (Q) "Terminal distributor of dangerous drugs" or "terminal distributor" means a person who is engaged in the sale of dangerous drugs at retail, or any person, other than a manufacturer, repackager, outsourcing facility, third-party logistics provider, wholesale distributor, or pharmacist, who has possession, custody, or control of dangerous drugs for any purpose other than for that person's own use and consumption. "Terminal distributor" includes pharmacies, hospitals, nursing homes, and laboratories and all other persons who procure dangerous drugs for sale or other distribution by or under the supervision of a pharmacist or licensed health professional authorized to prescribe drugs

14 Sub. H. B. No. 191 Page 14 (R) "Promote to the public" means disseminating a representation to the public in any manner or by any means, other than by labeling, for the purpose of inducing, or that is likely to induce, directly or indirectly, the purchase of a dangerous drug at retail. (S) "Person" includes any individual, partnership, association, limited liability company, or corporation, the state, any political subdivision of the state, and any district, department, or agency of the state or its political subdivisions. (T) "Animal shelter" means a facility operated by a humane society or any society organized under Chapter of the Revised Code or a dog pound operated pursuant to Chapter 955. of the Revised Code. (U) "Food" has the same meaning as in section of the Revised Code. (V) "Pain management clinic" has the same meaning as in section of the Revised Code. (W) "Investigational drug or product" means a drug or product that has successfully completed phase one of the United States food and drug administration clinical trials and remains under clinical trial, but has not been approved for general use by the United States food and drug administration. "Investigational drug or product" does not include controlled substances in schedule I, as established pursuant to section of the Revised Code, and as amended. (X) "Product," when used in reference to an investigational drug or product, means a biological product, other than a drug, that is made from a natural human, animal, or

15 Sub. H. B. No. 191 Page 15 microorganism source and is intended to treat a disease or medical condition. (Y) "Third-party logistics provider" means a person that provides or coordinates warehousing or other logistics services pertaining to dangerous drugs including distribution, on behalf of a manufacturer, wholesale distributor, or terminal distributor of dangerous drugs, but does not take ownership of the drugs or have responsibility to direct the sale or disposition of the drugs. (Z) "Repackager of dangerous drugs" or "repackager" means a person that repacks and relabels dangerous drugs for sale or distribution. (AA) "Outsourcing facility" means a facility that is engaged in the compounding and sale of sterile drugs and is registered as an outsourcing facility with the United States food and drug administration. Sec All of the following apply to the practice of respiratory care by a person who holds a license or limited permit issued under this chapter: (A) The person shall practice only pursuant to a prescription or other order for respiratory care issued by any of the following: (1) A physician; (2) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner who holds a current, valid license issued under Chapter of the Revised Code to practice nursing as an advanced practice registered nurse and has entered into a standard care arrangement with a physician;

16 Sub. H. B. No. 191 Page 16 (3) A certified registered nurse anesthetist who holds a current, valid license issued under Chapter of the Revised Code to practice nursing as an advanced practice registered nurse and acts in compliance with division (B) of section of the Revised Code; (4) A physician assistant who holds a valid prescriber number issued by the state medical board, has been granted physician-delegated prescriptive authority, and has entered into a supervision agreement that allows the physician assistant to prescribe or order respiratory care services. (B) The person shall practice only under the supervision of any of the following: (1) A physician; (2) A certified nurse practitioner, certified nursemidwife, or clinical nurse specialist; (3) A physician assistant who is authorized to prescribe or order respiratory care services as provided in division (A) (3) of this section. (C)(1) When practicing under the prescription or order of a certified nurse practitioner, certified nurse midwife, or clinical nurse specialist or under the supervision of such a nurse, the person's administration of medication that requires a prescription is limited to the drugs that the nurse is authorized to prescribe pursuant to section of the Revised Code. (2) When practicing under the order of a certified registered nurse anesthetist, the person's administration of medication is limited to the drugs that the nurse is authorized to order or direct the person to administer, as provided in

17 Sub. H. B. No. 191 Page 17 division (B) of section of the Revised Code. (3) When practicing under the prescription or order of a physician assistant or under the supervision of a physician assistant, the person's administration of medication that requires a prescription is limited to the drugs that the physician assistant is authorized to prescribe pursuant to the physician assistant's physician-delegated prescriptive authority. Section 2. That existing sections , , and of the Revised Code are hereby repealed